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JUDITH T. TERRY % ® F w 41, .7t, Town Hall, 53095 Main Road
TOWN CLERK % p.. kP.O. Box 1179
REGISTRAR OF VITAL STATISTICS = i Southold, New York 11971
MARRIAGE OFFICER � Fax (516) 765-1823
Telephone (5 6) 765-1801
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OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL PERMIT
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. 1664-R Residential X Non-Residential
Fee $ 10.00 Septic Cesspool X
New Existing X
Name Of Owner COLLINS / SCHULZE
Mailing Address 1 P. O. BOX 134
Mailing Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Property Address 1 6340 NEW SUFFOLK ROAD
Property Address 2
City St Zip NEW SUFFOLK NY 11956-0000
Owner Telephone No. 516-734-5119
Tax Map No. section 117.00 block 4 lot 32.000
Cross Street FANNING ROAD
Date Of Last Pump Out 0/00/00
Issue Date: 4/08/91 Judith T. Terry
Southold Town Clerk
(TOWN SEAL)
OFFIC ;P-•OF THE TOWN CLERK •
�FFO����'=
w ` Town of SoutholdUr
�� OG' Application No. /, , l
Judith T. Terry, Town Clerk . gy
Tow n Hall, 53095 Main Road °1:�,'t . $10.00 - Residential
P. 0. Box 1179 "=. '$25.00 - Non-Residential
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Southold, New York 11971
Telephone 62
(516) 765-1801
TOWN' OF SOUTHOLD
SOUTHOLD WASTEWATER DISPOSAL DISTRICT
APPLICATION
for
OPERATION PERMIT
SEPTIC TANK or CESSPOOL
Operation Permit No. •
'Fee' $
DATE t' c
OWNER NAME: k ltkak,' 60(-UfOs ?AUL ��-Ir UI. •
OWNER MAILING ADDRESS: -R5 50X 1"-
OWNER PROPERTY ,ADDDRESS: f )t -JVf- ( -Tap
Z,VrFOC
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OWNER TELEPHONE NUMBER: G- t�v '* ( �
TAX -MAP NO. : Section - Block 04 Lot - (937/-
CROSS
937/CROSS STREET: tv1 (
• TYPE OF SYSTEM:' Septic Tank New Existing
Cesspool New Existing
Residential Non-Residential
DATE OF PREVIOUS PUMP-OUT: a
LOCATION MAP: Must be attached hereto before permit may be issued.
(Locate building and system; give north arrow and feet
' of distance, approximately, -to building and closest road.)
Signa ure of Applicant
•
RECEIVED BY':
, . Town Clerk's Office
DATE: -
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